ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

ZERO GRACE/ZERO MALICE

Big companies and wealthy people make stupid mistakes too.

Your ancestors kept snakes and drank bad water. You (probably) don't because you've learnt from their failures via instinct+, the ultimate life-lessons streaming network in your head. Instincts foretell the future. If you approach a lion, it'll eat you. Our society's nuanced/complex decisions have surpassed instinct. Human growth depends on how we handle these issues. 80% of people believe they are above-average drivers, yet few believe they make many incorrect mistakes that make them risky. Stupidity hurts others like death. Basic Laws of Human Stupidity by Carlo Cipollas:

1. Everyone underestimates the prevalence of idiots in our society.

2. Any other trait a person may have has no bearing on how likely they are to be stupid.

3. A dumb individual is one who harms someone without benefiting themselves and may even lose money in the process.

4. Non-dumb people frequently underestimate how destructively powerful stupid people can be.

5. The most dangerous kind of person is a moron.

Professor Cippola defines stupid as bad for you and others. We underestimate the corporate world's and seemingly successful people's ability to make bad judgments that harm themselves and others. Success is an intoxication that makes you risk-aggressive and blurs your peripheral vision.

Stupid companies and decisions:

Big Dumber

Big-company bad ideas have more bulk and inertia. The world's most valuable company recently showed its board a VR headset. Jony Ive couldn't destroy Apple's terrible idea in 2015. Mr. Ive said that VR cut users off from the outer world, made them seem outdated, and lacked practical uses. Ives' design team doubted users would wear headsets for lengthy periods.

VR has cost tens of billions of dollars over a decade to prove nobody wants it. The next great SaaS startup will likely come from Florence, not Redmond or San Jose.

Apple Watch and Airpods have made the Cupertino company the world's largest jewelry maker. 10.5% of Apple's income, or $38 billion, comes from wearables in 2021. (seven times the revenue of Tiffany & Co.). Jewelry makes you more appealing and useful. Airpods and Apple Watch do both.

Headsets make you less beautiful and useful and promote isolation, loneliness, and unhappiness among American teenagers. My sons pretend they can't hear or see me when on their phones. VR headsets lack charisma.

Coinbase disclosed a plan to generate division and tension within its workplace weeks after Apple was pitched $2,000 smokes. The crypto-trading platform is piloting a program that rates staff after every interaction. If a coworker says anything you don't like, you should tell them how to improve. Everyone gets a 110-point scorecard. Coworkers should evaluate a person's rating while deciding whether to listen to them. It's ridiculous.

Organizations leverage our superpower of cooperation. This encourages non-cooperation, period. Bridgewater's founder Ray Dalio designed the approach to promote extreme transparency. Dalio has 223 billion reasons his managerial style works. There's reason to suppose only a small group of people, largely traders, will endure a granular scorecard. Bridgewater has 20% first-year turnover. Employees cry in bathrooms, and sex scandals are settled by ignoring individuals with poor believability levels. Coinbase might take solace that the stock is 80% below its initial offering price.

Poor Stupid

Fools' ledgers are valuable. More valuable are lists of foolish rich individuals.

Robinhood built a $8 billion corporation on financial ignorance. The firm's median account value is $240, and its stock has dropped 75% since last summer. Investors, customers, and society lose. Stupid. Luna published a comparable list on the blockchain, grew to $41 billion in market cap, then plummeted.

A podcast presenter is recruiting dentists and small-business owners to invest in Elon Musk's Twitter takeover. Investors pay a 7% fee and 10% of the upside for the chance to buy Twitter at a 35% premium to the current price. The proposal legitimizes CNBC's Trade Like Chuck advertising (Chuck made $4,600 into $460,000 in two years). This is stupid because it adds to the Twitter deal's desperation. Mr. Musk made an impression when he urged his lawyers to develop a legal rip-cord (There are bots on the platform!) to abandon the share purchase arrangement (for less than they are being marketed by the podcaster). Rolls-Royce may pay for this list of the dumb affluent because it includes potential Cullinan buyers.

Worst company? Flowcarbon, founded by WeWork founder Adam Neumann, operates at the convergence of carbon and crypto to democratize access to offsets and safeguard the earth's natural carbon sinks. Can I get an ayahuasca Big Gulp?

Neumann raised $70 million with their yogababble drink. More than half of the consideration came from selling GNT. Goddess Nature Token. I hope the company gets an S-1. Or I'll start a decentralized AI Meta Renewable NFTs company. My Community Based Ebitda coin will fund the company. Possible.

Stupidity inside oneself

This weekend, I was in NYC with my boys. My 14-year-old disappeared. He's realized I'm not cool and is mad I let the charade continue. When out with his dad, he likes to stroll home alone and depart before me. Friends told me hell would return, but I was surprised by how fast the eye roll came.

Not so with my 11-year-old. We went to The Edge, a Hudson Yards observation platform where you can see the city from 100 storeys up for $38. This is hell's seventh ring. Leaning into your boys' interests is key to engaging them (dad tip). Neither loves Crossfit, WW2 history, or antitrust law.

We take selfies on the Thrilling Glass Floor he spots. Dad, there's a bar! Coke? I nod, he rushes to the bar, stops, runs back for money, and sprints back. Sitting on stone seats, drinking Atlanta Champagne, he turns at me and asks, Isn't this amazing? I'll never reach paradise.

Later that night, the lads are asleep and I've had two Zacapas and Cokes. I SMS some friends about my day and how I feel about sons/fatherhood/etc. How I did. They responded and approached. The next morning, I'm sober, have distance from my son, and feel ashamed by my texts. Less likely to impulsively share my emotions with others. Stupid again.

Many of us have struggled for years to master a second language (in my case, English). Because (at least in my situation) we've always used an input-based system or method.

I'll explain in detail, but briefly: We can understand some conversations or sentences (since we've trained), but we can't give sophisticated answers or speak fluently (because we have NOT trained at all).

What exactly is input-based learning?

Reading, listening, writing, and speaking are key language abilities (if you look closely at that list, it seems that people tend to order them in this way: inadvertently giving more priority to the first ones than to the last ones).

These talents fall under two learning styles:

• Reading and listening are input-based activities (sometimes referred to as receptive skills or passive learning).

• Writing and speaking are output-based tasks (also known as the productive skills and/or active learning).

What's the best learning style? To learn a language, we must master four interconnected skills. The difficulty is how much time and effort we give each.

According to Shion Kabasawa's books The Power of Input: How to Maximize Learning and The Power of Output: How to Change Learning to Outcome (available only in Japanese), we spend 7:3 more time on Input Based skills than Output Based skills when we should be doing the opposite, leaning more towards Output (Input: Output->3:7).

I can't tell you how he got those numbers, but I think he's not far off because, for example, think of how many people say they're learning a second language and are satisfied bragging about it by only watching TV, series, or movies in VO (and/or reading a book or whatever) their Input is: 7:0 output!

You can't be good at a sport by watching TikTok videos about it; you must play.

“being pushed to produce language puts learners in a better position to notice the ‘gaps’ in their language knowledge”, encouraging them to ‘upgrade’ their existing interlanguage system. And, as they are pushed to produce language in real time and thereby forced to automate low-level operations by incorporating them into higher-level routines, it may also contribute to the development of fluency. — Scott Thornbury (P is for Push)

How may I practice output-based learning more?

I know that listening or reading is easy and convenient because we can do it on our own in a wide range of situations, even during another activity (although, as you know, it's not ideal), writing can be tedious/boring (it's funny that we almost always excuse ourselves in the lack of ideas), and speaking requires an interlocutor. But we must leave our comfort zone and modify our thinking to go from 3:7 to 7:3. (or at least balance it better to something closer). Gradually.

“You don’t have to do a lot every day, but you have to do something. Something. Every day.” — Callie Oettinger (Do this every day)

We can practice speaking like boxers shadow box.

Speaking out loud strengthens the mind-mouth link (otherwise, you will still speak fluently in your mind but you will choke when speaking out loud). This doesn't mean we should talk to ourselves on the way to work, while strolling, or on public transportation. We should try to do it without disturbing others, such as explaining what we've heard, read, or seen (the list is endless: you can TALK about what happened yesterday, your bedtime book, stories you heard at the office, that new kitten video you saw on Instagram, an experience you had, some new fact, that new boring episode you watched on Netflix, what you ate, what you're going to do next, your upcoming vacation, what’s trending, the news of the day)

Who will correct my grammar, vocabulary, or pronunciation with an imagined friend? We can't have everything, but tools and services can help [1].

Lack of bravery

Fear of speaking a language different than one's mother tongue in front of native speakers is global. It's easier said than done, because strangers, not your friends, will always make fun of your accent or faults. Accept it and try again. Karma will prevail.

Perfectionism is a trap. Stop self-sabotaging. Communication is key (and for that you have to practice the Output too ).

“Don’t forget to have fun and enjoy the process.” — Ruri Ohama

[1] Grammarly, Deepl, Google Translate, etc.

People are slowly recognizing entrepreneurship's downside.

Growing up, entrepreneurship wasn't common. High school class of 2012 had no entrepreneurs.

Businesses were different.

They had staff and a lengthy history of achievement.

I never wanted a business. It felt unattainable. My friends didn't care.

Weird.

People desired degrees to attain good jobs at big companies.

When graduated high school:

• 9 out of 10 people attend college

• Earn minimum wage (7%) working in a restaurant or retail establishment

• Or join the military (3%)

Later, entrepreneurship became a thing.

2014-ish

I was in the military and most of my high school friends were in college, so I didn't hear anything.

Entrepreneurship soared in 2015, according to Google Trends.

Then more individuals were interested. Entrepreneurship went from unusual to cool.

In 2015, it was easier than ever to build a website, run Facebook advertisements, and achieve organic social media reach.

There were several online business tools.

You didn't need to spend years or money figuring it out. Most entry barriers were gone.

Everyone wanted a side gig to escape the 95.

Small company applications have increased during the previous 10 years.

2011-2014 trend continues.

2015 adds 150,000 applications. 2016 adds 200,000. Plus 300,000 in 2017.

The graph makes it look little, but that's a considerable annual spike with no indications of stopping.

By 2021, new business apps had doubled.

Entrepreneurship will return to its early 2010s level.

I think we'll go backward in 5 years.

Entrepreneurship is half as popular as it was in 2015.

In the late 2020s and 30s, entrepreneurship will again be obscure.

Entrepreneurship's decade-long splendor is fading. People will cease escaping 9-5 and launch fewer companies.

That’s not a bad thing.

I think people have a rose-colored vision of entrepreneurship. It's fashionable. People feel that they're missing out if they're not entrepreneurial.

Reality is showing up.

People say on social media, "I knew starting a business would be hard, but not this hard."

More negative posts on entrepreneurship:

Luke adds:

Is being an entrepreneur ‘healthy’? I don’t really think so. Many like Gary V, are not role models for a well-balanced life. Despite what feel-good LinkedIn tells you the odds are against you as an entrepreneur. You have to work your face off. It’s a tough but rewarding lifestyle. So maybe let’s stop glorifying it because it takes a lot of (bleepin) work to survive a pandemic, mental health battles, and a competitive market.

Entrepreneurship is no longer a pipe dream.

It’s hard.

I went full-time in March 2020. I was done by April 2021. I had a good-paying job with perks.

When that fell through (on my start date), I had to continue my entrepreneurial path. I needed money by May 1 to pay rent.

Entrepreneurship isn't as great as many think.

Entrepreneurship is a serious business.

If you have a 9-5, the grass isn't greener here. Most people aren't telling the whole story when they post on social media or quote successful entrepreneurs.

People prefer to communicate their victories than their defeats.

Is this a bad thing?

I don’t think so.

Over the previous decade, entrepreneurship went from impossible to the finest thing ever.

It peaked in 2020-21 and is returning to reality.

Startups aren't for everyone.

If you like your job, don't quit.

Entrepreneurship won't amaze people if you quit your job.

It's irrelevant.

You're doomed.

And you'll probably make less money.

If you hate your job, quit. Change jobs and bosses. Changing jobs could net you a greater pay or better perks.

When you go solo, your paycheck and perks vanish. Did I mention you'll fail, sleep less, and stress more?

Nobody will stop you from pursuing entrepreneurship. You'll face several challenges.

Possibly.

Entrepreneurship may be romanticized for years.

Based on what I see from entrepreneurs on social media and trends, entrepreneurship is challenging and few will succeed.